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BACKGROUND With a 13 percent global prevalence, migraine headaches are the most commonly diagnosed neurologic disorder, and are a top five cause of visits to the emergency room. Surgical techniques, such as decompression and/or ablation of neurovasculature, have shown to provide relief. Popular diagnostic modalities to identify trigger loci include handheld Doppler examinations and botulinum toxin injection. This article aims to establish the positive predictive value of peripheral nerve blocks for identifying therapeutic surgical targets for migraine headache surgery. METHODS Electronic medical records of 36 patients were analyzed retrospectively. Patients underwent peripheral nerve blocks using 1% lidocaine with epinephrine and subsequent surgery on identified migraine headache trigger sites. Patients were grouped into successful and unsuccessful blocks and further categorized into successful and unsuccessful surgery subgroups. Group analysis was performed using paired t tests, and positive-predictive value calculations were performed on subgroups. RESULTS The preoperative Migraine Headache Index of patients with positive blocks was 152.71, versus 34.26 postoperatively (p < 0.001). Each index component also decreased significantly: frequency (22.11 versus 15.06 migraine headaches per month; p < 0.001), intensity (7.43 versus 4.12; p < 0.001), and duration (0.93 versus 0.55 days; p < 0.001). The positive-predictive value of diagnostic peripheral nerve blocks in identifying a migraine headache trigger site responsive to surgical intervention was calculated to be 0.89 (95 percent CI, 1 to 0.74). CONCLUSIONS To the authors' knowledge, this is the first study to investigate the positive-predictive value of peripheral nerve blocks as used in the diagnostic workup of patients with chronic migraine headaches. Peripheral nerve blocks serve as a reliable clinical tool in mapping migraine trigger sites for surgical intervention while offering more flexibility in their administration and recording as compared to established diagnostic methods. . CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, IV.

Background Kidney autotransplantation (KAT) is the ultimate approach for nephron-sparing surgery. It is a rarely used method in renal tumor surgery today as minimal invasive and open techniques for nephron-sparing surgery improve constantly. In this publication, the complication rate and the long-term functional and oncological outcome at a single center are analyzed. Methods A prospectively constructed database of patients with renal tumors who underwent renal surgery was retrospectively analyzed to identify patients with KAT and describe surgical and oncological outcomes and to obtain long-term follow-up. Data collection included detailed surgical technique, complications (Clavian-Dindo), and hospital stay, as well as functional and oncological outcome and long-term follow-up. Results Between 1976 and 2013, 12 patients (median age 50.5 years) underwent KAT for highly complex renal masses: in five cases for complex renal cell carcinoma (RCC), five cases for complex upper urinary tract carcinoma (UTUC), one case for a renal metastasis, and one case for nephroblastoma. The nephrectomy or nephron-ureterectomy was performed open via a flank or transabdominal. The median surgical time was 360 min (range 270–490 min). Intraoperatively, six cases required blood transfusions (50%). Six patients (50%) developed significant postoperative complications (Clavian-Dindo > 2). In two patients, intermittent hemodialysis for delayed graft function (16.6%) was needed, and in six cases (50%), additional blood transfusions postoperatively were necessary. At discharge from hospital, all patients had functioning grafts. The median hospital stay was 29.5 days (range 18–35). At follow-up (median follow-up of 83.5 ± 40.7 months), six patients had died (50%)—all with functioning grafts (free from hemodialysis). In five cases, recurrence of primary tumor or metastatic disease was recorded. In four cases, the recurrent carcinoma could be resected; in detail, UTUC in three cases and one partial nephrectomy of the autotransplanted kidney was performed. One patient suffered from bone and lung metastasis. Two patients died finally tumor-related. Five patients (41.6%) are presently alive, without evidence of tumor relapse. One patient developed terminal renal failure requiring hemodialysis 105 months after autotransplantation. One additional patient was lost to follow-up; after 69 months, this patient had a functioning kidney and no evidence of disease-recurrence at the last follow-up. A cumulative number of 1424 months without hemodialysis was gained for these 12 patients. In the literature to date, most KAT are performed in benign disease, with minor but frequent complication. Here, we report the largest series of KAT for malignant kidney tumors. The complication rates are similar, compared to the recently reported series for benign indications with an improved graft survival rate. Since KAT requires a complex and challenging surgical approach, it should be performed by experienced kidney transplant surgeons. Conclusion In very complex cases involving renal tumors and multi-morbidity, patients should be counseled well before KAT is considered. At the same time, KAT should not be abandoned in these very rare cases, especially when a nephron-sparing approach is otherwise not feasible. KAT can maintain renal function and quality of life and extend expectancy of life.

We present an endovascular approach for anatomic reconstruction of the iliac bifurcation in life-threatening arterioureteral fistula without sacrificing the pelvic arterial vascular supply. Five consecutive patients suffering from acute onset of significant gross hematuria caused by iliac-ureteral fistula resulting from previous oncologic surgery and radiation therapy were treated by transfemoral stent graft implantation in a double-barrel technique. Iliac-ureteral pseudoaneurysm coverage succeeded in an iliac neobifurcation with preservation of pelvic perfusion. Follow-up ranging from 9 to 37 months confirmed cessation of hematuria. One patient experienced stent graft thrombosis of the external iliac artery as a result of large cervical cancer invasion treated by crossover bypass. In all other patients, stent grafts were patent.

Background Facial vascularized composite allotransplantation (fVCA) represents a reconstructive approach that enables superior improvements in functional and esthetic restoration compared to conventional craniomaxillofacial reconstruction. Outcome reports of fVCA are usually limited to short-term follow-up or single-center experiences. We merge scientific literature on reported long-term outcome data to better define the risks and benefits of fVCA. Methods We conducted a systematic review of PubMed/MEDLINE databases in accordance with PRISMA guidelines. English full-text articles providing data on at least 1 unique fVCA patient, with ≥ 3 years follow-up, were included. Results The search yielded 1812 articles, of which 28 were ultimately included. We retrieved data on 23 fVCA patients with mean follow-up of 5.3 years. More than half of the patients showed improved quality of life, eating, speech, and motor and sensory function following fVCA. On average, the patients had 1 acute cell-mediated rejection and infectious episode per year. The incidence rates of acute rejection and infectious complications were high within first year posttransplant but declined thereafter. Sixty-five percent of the patients developed at least 1 neoplastic and/or metabolic complication after transplantation. Chronic vascular rejection was confirmed in 2 patients, leading to allograft loss after 8 and 9 years. Two patient deaths occurred 3.5 and 10.5 years after transplant due to suicide and lung cancer, respectively. Conclusions Allograft functionality and improvements in quality of life suggest a positive risk-benefit ratio for fVCA. Recurrent acute rejection episodes, chronic rejection, immunosuppression related complications, and heterogeneity in outcome reporting present ongoing challenges in this field.

There is considerable debate in the literature with relation to the best method to treat patients with chronic venous disease (CVD). CHIVA is an office-based treatment for varicose veins performed under local anesthesia. The aim of the technique is to lower transmural pressure in the superficial venous system and avoid destruction of veins. Recurrence of varicosities, nerve damage, bruising and suboptimal aesthetic results are common to all treatments for the disease. This paper evaluates and discusses the characteristics and results of the CHIVA technique. We conclude that CHIVA is a viable alternative to common procedures that is associated with less bruising, nerve damage, and recurrence than stripping saphenectomy. The main advantages are preservation of the saphenous vein, local anesthesia, low recurrence rates, low cost, low pain, and no nerve damage. The major disadvantages are the learning curve and the need to train the team in venous hemodynamics. Resumo Existe uma grande discussão na literatura sobre o tratamento da doença venosa crônica (DVC). A cura conservadora e hemodinâmica da insuficiência venosa em ambulatório (CHIVA) consiste no tratamento ambulatorial de varizes sob anestesia local. O objetivo da técnica é diminuir a pressão transmural no sistema venoso superficial para evitar a destruição das veias, incluindo as veias safenas. Recorrência de varizes, lesão de nervos, hematomas e resultado estético abaixo do ideal são uma constante em todos tratamentos de varizes. O objetivo desta revisão é avaliar e discutir a técnica CHIVA quanto a suas características e resultados. A CHIVA é uma alternativa válida frente aos outros procedimentos, apresentando menos hematomas, recorrência e lesão nervosa que a safenectomia. Preservação da veia safena, anestesia local, baixa taxa de recorrências, baixo custo, pouca dor e ausência de lesões nervosas são as principais vantagens. A longa curva de aprendizado para treinar a equipe em hemodinâmica venosa é a principal desvantagem.

Summary Background The use of acellular dermal matrices (ADMs) in immediate two-stage prosthetic breast reconstruction following mastectomy is now a common practice. The procedure confers several compelling benefits, including coverage of the inferior pole, enhanced definition of the inframammary fold, and reduction of capsular contracture. However, operative techniques used to create the ADM inferolateral sling can be unwieldy in practice, typically involving the placement of the ADM followed by positioning and anchoring of the prosthetic expander. At best, this may be a relatively minor nuisance, but may potentially influence outcomes, including discrepancies in symmetry. Methods We present a novel modification that aims to streamline this procedure. Perforations are made through the allograft, through which the tissue expander tabs are brought through and sutured together ex vivo to allow the ADM and expander to be placed into the inframammary fold position as a single unit. A retrospective chart review was then performed of patients who underwent breast reconstruction utilizing this technique between July 2015 and December 2018. Outcomes including postsurgical complications such as infection, malposition, and reoperation were analyzed. Results Sixty-two patients met the inclusion criteria, corresponding to 108 breasts. The average follow-up was 18 months. The overall complication rate was 29.6% of breasts. The most commonly observed complications were mastectomy skin necrosis (9.3%) and major infection (8.3%). There was a 7.4% rate of malposition. Conclusions This simple but effective modification in ADM technique is associated with a comparable complication rate and allows for greater ease and consistency in tissue expander placement.

Background: The use of wedge inferior pubectomy can be challenging to many urethral surgeons. Our objective was to introduce a bone-nibbling technique to accomplish a partial inferior pubectomy (PIP) in a resource-poor setting, and to report the medium- to longterm outcome of using the technique. Methods: Five patients were recruited (mean age: 38.8 years) who presented, over a 30-month period, with posterior urethral fibrosis from a pelvic fracture urethral injury (PFUI). One had failed a previous attempt at posterior urethral reconstruction elsewhere. The length of urethral defect was from 2 to 4 cm. We describe a bone-nibbling technique used to carry out PIP for the delayed repair of PFUI in these patients. The outcomes in the medium to long term of surgical procedures done with this technique are presented. Results: Immediate postoperative complications in all were essentially a Clavien–Dindo grade I. Peak flow rate assessed 12 weeks’ post operation was between 20 mL/s and 23 mL/s (mean: 21 mL/s). The longest duration of follow-up was 34 months, and all patients were voiding satisfactorily. Conclusions: A satisfactory and durable outcome can be obtained from nibbling at the bone from the inferior margin of the pubic bone to achieve PIP. This is of interest to lower urinary tract reconstructive surgeons who have concerns with chiseling-out wedge of the inferior pubis. Keywords: Bone nibbling, Partial inferior pubectomy, PFUI, Posterior urethra, Urethral anastomosis

Recently, the Hospital at Tabarre in Port-au-Prince Haiti was reopened by the Operational Center of Paris—Médecins Sans Frontières (MSF). This hospital is now purely a Trauma Center staffed by five national general surgeons and five orthopedic surgeons. MSF hopes that the new trauma focus of Tabarre Hospital and the presence of a full complement of experienced national surgeons can enable this site to become one of the training sites for exptriate surgeons on their first humanitarian mission with MSF. The general surgical case charts from the first 3 months after the reopening of the hospital were retrospectively reviewed. All procedures done by the general surgical department in the operating room theatre were registered and short and long-term results analyzed. The Hospital at Tabarre has a very high rate of penetrating traumas compared to other MSF hospitals, and seems ideally suited to train expatriate surgeons during their first missions in the field with MSF because of the experience of the National surgical staff. Additionally, it is felt that a longer Field General Surgery fellowship can and should be developed within MSF to ensure that the next generation of general surgeons can continue to provide the type of surgical care that is still needed in the field.

After decades of pioneering advances and improvements, kidney transplantation is now the renal replacement therapy of choice for most patients with end-stage kidney disease (ESKD). Despite this success, the high risk of premature death and frequent occurrence of graft failure remain important clinical and research challenges. The current burst of studies and other innovative initiatives using artificial intelligence (AI) for a wide range of analytical and practical applications in biomedical areas seems to correlate with the same trend observed in publications in the kidney transplantation field, and points toward the potential of such novel approaches to address the aforementioned aim of improving long-term outcomes of kidney transplant recipients (KTR). However, at the same time, this trend underscores now more than ever the old methodological challenges and potential threats that the research and clinical community needs to be aware of and actively look after with regard to AI-driven evidence. The purpose of this narrative mini-review is to explore challenges for obtaining applicable and adequate kidney transplant data for analyses using AI techniques to develop prediction models, and to propose next steps in the field. We make a call to act toward establishing the strong collaborations needed to bring innovative synergies further augmented by AI, which have the potential to impact the long-term care of KTR. We encourage researchers and clinicians to submit their invaluable research, including original clinical and imaging studies, database studies from registries, meta-analyses, and AI research in the kidney transplantation field.

Background Intussusception is the one of the commonest causes of intestinal obstruction requiring urgent attention in early childhood. There is no gold standard of non-operative reduction. We report our 6 years’ experience in non-operative reduction using our “RIGHT” (Reduction of Intussusception under General anesthesia using Hydrostatic Technique) technique, emphasizing the need to perform the procedure in the operating room (OR) under general anesthesia. This prospective observational study covering the period from July 2014 till May 2020 included patients diagnosed with intussusception. Hydrostatic reduction was performed in the OR under general anesthesia by infusing a saline enema and the reduction was confirmed by ultrasound. Results Forty-eight patients underwent reduction using the RIGHT technique. Successful reduction was achieved in 44 (91.6%) patients. Four (8.3%) patients needed surgery, three (6.2%) due to failed reduction and one (2.0%) due to perforation. One (2.2%) patient developed a recurrence. Conclusions The “RIGHT” technique is a combination of the best available techniques of reduction of intussusception. It ensures patient safety by being performed in the OR, being pain free, avoiding radiation, avoiding the risk of aspiration associated with sedation, and also being able to immediately address a failure of reduction or a complication by surgical exploration.

Background Sudden Sensorineural Hearing Loss (SSNHL) is a medical emergency requiring immediate attention as delayed treatment can lead to permanent and devastating consequences. Primary care physicians are likely the first to be presented with SSNHL and therefore have the crucial role of recognizing it and initiating timely and appropriate management. The aim of this study was to gain insight into the current knowledge and practice trends pertaining to the diagnosis and management of SSNHL among family physicians in Canada. Methods An 18-question survey targeting Canadian family physicians was marketed through two, physician-only discussion groups on the social media platform Facebook. Responses were collected between August 1st and December 22nd 2019 then aggregated and quantified. Results 52 family physicians submitted responses. 94.2% (n = 49) reported that in their practice, unilateral SSNHL warrants urgent referral to otolaryngology and 84.6% (n = 44) reported that unilateral sudden-onset hearing loss warrants urgent referral for audiological testing. 73.1% of participants (n = 38) reported that they would attempt to differentiate between conductive and sensorineural hearing loss if presented with unilateral, acute or sudden-onset hearing loss. 61.5% (n = 32) would rely on tuning fork tests to inform management decisions, as compared to 94.2% (n = 49) relying on case history and 88.5% (n = 46) on otoscopy. 76.9% (n = 40) would prescribe corticosteroids if presented with confirmed, unilateral SSNHL. Conclusion The majority of family physicians in the study would make appropriate referral and treatment decisions in the management of SSNHL, understanding it is a medical emergency. Tuning fork tests are under-utilized for informing management decisions compared to other means of differentiating conductive and sensorineural hearing loss. Further research is needed to understand why some family physicians do not prescribe corticosteroids for treatment of SSNHL, which may then identify any gaps in knowledge or inform improvements in clinical protocol. Graphical abstract

Background Postoperative rectourethral fistula (RUF) in patients with congenital anorectal malformation (ARM) remains a challenge for paediatric surgeons, among them persistent fistula is the most common. Various techniques have been proposed, only a few reports based on different causes are available, and there is no consensus so far. This study is to evaluate the application, advantages and limitations of transanal fistulectomy approach in repairing persistent RUF in ARM patients. Methods From January 2007 to July 2019, 78 ARM patients who received revisional surgery for RUF were reviewed, 34 persistent fistulas were identified. Examination under anaesthesia included patients with fistulas that were located within 3 cm from the anus verge, good appearance of the anus and sphincter function, and no urethral and rectoanal obstruction. Three patients were excluded because of complex urologic pathologic defects. In total, thirty-one patients underwent transanal fistulectomy to repair RUF. Results All cases were approached with transanal incision and fistulectomy to repair RUF. The average operative time was 91 ± 35 min. At a minimum six-month follow-up, 29 patients healed after the first attempt, the success closure rate was 93.5%. Two patients received redo transanal fistulectomy and healed. Two patients had postoperative complications: one patient had urethral stenosis and it was managed by dilation; one patient had urethral diverticulum but it did not require revisional surgery. No patient in this study was incontinent because of the surgery. Conclusions Transanal fistulectomy provides a simple, straightforward, and safe approach to repair persistent RUF in ARM patients, especially in those with a low-lying fistula, good anus appearance and sphincter function without obstruction in the rectum or urethra. Trial registration: Retrospectively registered.

Острое повреждение почек и его несвоевременная диагностика часто приводят к увеличению числа пациентов с хронической болезнью почек. Нельзя отрицать важность изучения патогенетических механизмов реализации острого повреждения почек, своевременной предиктивной идентификации пациентов высокого риска острого повреждения почек, ассоциированного с кардиохирургией, а также необходимость поиска и совершенствования периоперационных стратегий по предупреждению острого повреждения почек, ассоциированного с кардиохирургической операцией. Разработка новых подходов к предиктивной диагностике кардиохирургического острого повреждения почек и повсеместное внедрение их в широкую клиническую практику позволит улучшить прогноз и выживаемость этой категории больных.Современный диагностический континуум острого повреждения почек рассматривает факторы риска в качестве предсуществующих условий, на фоне которых реализуются неблагоприятные факторы периоперационного периода. Факторы риска острого повреждения почек в кардиохирургии условно разделяются на две категории: 1) пациент-зависимые; 2) связанные с кардиохирургической операцией, в той или иной степени обусловленные ятрогенными воздействиями (неблагоприятными факторами периоперационного периода). Четкое понимание значения этих факторов для развития острого почечного повреждения у кардиохирургических больных позволяет сформировать шкалы риска прогнозирования острого почечного повреждения в послеоперационном периоде. В обзоре представлены знаковые для предиктивной диагностики острого повреждения почек в кардиохирургии работы: модель Ассоциации нефрологов и Ассоциации анестезиологов-реаниматологов России, шкала EuroSCORE-II, шкала STS, шкала R.H. Mehta и соавт., индекс риска периоперационной почечной дисфункции / недостаточности S. Aronson и соавт., шкала S.Y. Ng и соавт., модель К. Birnie и соавт.Применение прогностических моделей для предиктивной диагностики острого повреждения почек, ассоциированного с кардиохирургической операцией, является важной стратегией для идентификации пациентов высокого риска. Данный подход позволяет широко применять превентивные стратегии для предупреждения развития острого повреждения почек в рутинной клинической практике и обладает преимуществами при проведении когортных клинических исследований новых ренопротективных технологий. Ни одна шкала прогнозирования риска кардиохирургического острого повреждения почек не является «золотым стандартом» предиктивной диагностики. Авторы предлагают рассматривать их применение согласно конкретной клинической ситуации.Поступила в редакцию 10 июля 2020 г. Исправлена 9 сентября 2020 г. Принята к печати 10 сентября 2020 г.Конфликт интересовАвторы заявляют об отсутствии конфликта интересов.ФинансированиеИсследование не имело спонсорской поддержки.Вклад авторовКонцепция и дизайн работы: Н.О. Каменщиков, Ю.К. Подоксенов, М.Л. Дьякова Написание статьи: Н.О. Каменщиков, М.Л. Дьякова, А.М. Бойко Исправление статьи: М.Л. Дьякова, Ю.К. Подоксенов Утверждение окончательного варианта статьи: все авторы

Background The accuracy of hepatobiliary scintigraphy to assess gallbladder function remains controversial. National supply shortages of pharmaceutical-grade cholecystokinin led to the use of an oral fatty meal to stimulate gallbladder contraction during hepatobiliary scintigraphy. The goal of this study was to compare the predictive indices of cholecystokinin and fatty meal ingestion for stimulation of gallbladder contraction. Methods Patients evaluated with hepatobiliary iminodiacetic acid scan from 2014 to 2017 were reviewed and grouped based on testing stimulant (fatty meal versus cholecystokinin). Patients who later underwent cholecystectomy were selected for analysis. Hepatobiliary iminodiacetic acid results were correlated with surgical pathology and postoperative resolution of symptoms. Two-way statistical analysis was performed. Results A total of 359 patients underwent hepatobiliary iminodiacetic acid scan followed by cholecystectomy for biliary dyskinesia. Patients who received fatty meal stimulant (n = 86) were compared to those that received cholecystokinin (n = 273). Mean gallbladder ejection fraction during hepatobiliary iminodiacetic acid was 38% and 44% for the cholecystokinin and fatty meal groups, respectively, P = .073. Predictive metrics were not statistically different between groups with regard to pathology, symptomatic improvement, or accuracy. Symptomatic resolution (cholecystokinin–hepatobiliary iminodiacetic acid 78%, fatty meal–hepatobiliary iminodiacetic acid 68%; P = 0.058) and specificity (cholecystokinin–hepatobiliary iminodiacetic acid 26%, fatty meal–hepatobiliary iminodiacetic acid 44%, P = 0.417) were comparable in both testing groups. Conclusion Stimulation of gallbladder contraction with a fatty meal during hepatobiliary iminodiacetic acid testing is a more affordable and reliable alternative to cholecystokinin for patients undergoing evaluation for gallbladder dysmotility., Highlights • Use of a fatty meal as a stimulant for hepatobiliary iminodiacetic acid scan. • Affordable alternative to cholecystokinin for a hepatobiliary iminodiacetic acid scan. • Comparison of 2 stimulants used for hepatobiliary iminodiacetic acid scan. • Reliable alternative to IV cholecystokinin for hepatobiliary iminodiacetic acid scans.

Background. Interventions on the thoracic aorta involving prolonged artificial circulation, clamping of the aorta and extensive dissection of the mediastinal structures are associated with a higher incidence of pericardial effusion and cardiac tamponade compared to other interventions. We suggest that routine implementation of posterior pericardiotomy may significantly affect the incidence of postoperative pericardial effusion syndrome and cardiac tamponade after interventions on the thoracic aorta.Aim. Evaluation of the effectiveness of posterior pericardiotomy regarding the development of cardiac tamponade, effusion pericarditis and the postoperative course of patients in the early period after interventions on the thoracic aorta.Methods. We conducted a retro- and prospective study that included 100 patients with thoracic aorta pathologies who were operated on in the cardiac surgery department of clinic from 2017 to 2020. All subjects were divided into two groups: a treatment group of 40 patients who underwent routine posterior pericardiotomy, and a control group of 60 patients without posterior pericardiotomy but with standard installation of postoperative drains. Assessment of the effect of posterior pericardiotomy on pericardial effusion, cardiac tamponade and the early postoperative period was conducted on the basis of transthoracic echocardiography that was performed daily during hospitalisation (the maximum amount of effusion during the observation period was taken as the control point), as well as up to one month after discharge from hospital.Results. The study groups did not differ regarding parameters such as time of artificial circulation (p = 0.39), time of myocardial ischaemia (p = 0.42), length of intensive care unit stay (p = 0.79) and length of hospitalisation (p = 0.21). Evaluation of pericardial effusion of varying severity during hospital follow-up revealed its presence in 15 (37.5%) patients in the PPt group and in 54 (90%) in the control group (p = 0.0001). Early postoperative cardiac tamponade developed in 4 (6.7%) patients in the control group, but was not observed in the PPt group (p = 0.09). At the same time, 5 (8.3%) patients without pericardiotomy required pericardiocentesis; however, this procedure was not performed in the PPt group (p = 0.06). Additionally, we did not find a statistically significant difference between the groups in relation to the frequency of puncture of the left pleural cavity (37.5% in the PPt group versus 43.3% in the control group, p = 0.56). According to the results of control echocardiography after one month, effusion of varying severity was found in 21 (35%) patients in the control group versus 1 (2.5%) in the PPt group (p = 0.0001).Conclusion. Posterior pericardiotomy is an affordable, applicable, safe and effective method for preventing postoperative pericardial effusion and cardiac tamponade after thoracic aortic surgery. This manipulation did not significantly affect the length of hospitalisation or the incidence of postoperative atrial fibrillation in this cohort of patients. Posterior pericardiotomy is not associated with a more frequent need for puncture of the left pleural cavity.Received 13 October 2020. Revised 10 December 2020. Accepted 11 December 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

Background: The educational environment (EE) has a significant influence on effective student learning. The Dundee Ready Education Environment Measure (DREEM) is a validated tool to assess the EE. A DREEM survey done in early 2019 among medical students at the University of Nairobi highlighted many problems. It was therefore important to explore why such perceptions existed among the medical students. Objectives: To explore medical students’ perceptions ofthe medical education learning environment at the University of Nairobi. Methods: Qualitative focus group discussions (FGD) were held among medical students in years III to VI in groups of between 8and 12students. The discussions were recorded using a Samsung J6 phone voice recorder, transcribed, coded, and analysed for themes until saturation was reached. Results: We held six FGD with medical students in years III to VI and identified four thematic areas: 1) poor educational infrastructure, 2) poor educational structure, 3) teacher-centred teaching, and 4) lack of social support for students in difficulties. Conclusion: Exploring the perceptions of the EE confirmed students have a poor view of the educational environment. The issues raised are good feedback on teaching, governance and the social culture of the institution. Keywords: Learning environment, DREEM, Medical students, Qualitative methods

Background/objective: This study’s goal is to describe wound outcomes at 2 years following intervention for atherosclerotic femoropopliteal lesions in patients with ischemic tissue loss. Methods: A retrospective review of 135 first-time endovascular procedures for chronic femoropopliteal atherosclerotic lesions related to ischemic tissue loss was performed. The final wound outcomes were categorized according to the initial wound healing, recurrence and the need of major/minor amputation. Results: At 2-years of follow up, 76 limbs (56.3%) showed complete wound healing without recurrence, however, wound development occurred at other sites on the same foot following complete primary healing in 11 limbs (8.1%). Tolerable wounds persisted or wounds recurred at the same site in 30 limbs (22.2%), and 18 limbs (13.3%) needed major amputations. Independent factors that prevented wound healing without recurrence at 2 years were renal insufficiency (HR = 0.225, 95% C.I. = 0.091–0.556, p = 0.001), ankle pressure < 50 mmHg or flat forefoot PVR (HR = 0.328, 95% C.I. = 0.124–0.867, p = 0.025) and functional performance < 4 metabolic equivalents (MET) (HR = 0.150, 95% C.I. = 0.063–0.360, p

Objective To identify differentiation features of chemosensory dysfunction in COVID‐19 infection and their primary drivers. Study Design Cross‐sectional cohort comparison. Methods A national anonymous survey was used to query participants regarding nasal symptoms and chemosensory dysfunction including sensitivity levels, and presence or absence of distortions and phantoms within the 6‐week time window surrounding their COVID‐19 testing and survey completion. Results Three‐hundred and sixty‐four respondents who reported COVID‐19 positive (COVID+; n = 176) or COVID‐19 negative (COVID−; n = 188) test results completed the survey. The COVID+ cohort had higher occurrence rates for: (a) chemosensory sensitivity impairments (67.0% vs 30.3%; P, In the COVID+ cohort, a higher rate of absent smell or taste is associated with a higher rate of chemosensory distortions compared to the COVID− cohort. COVID+, N=176; COVID−, N=188.

Background Metachronous pancreatic and gallbladder cancer is a rare condition and has a dismal prognosis. Herein, we present a patient with triple metachronous primary pancreatic and gallbladder cancer associated with pancreaticobiliary maljunction who achieved long-term survival after undergoing repeat curative surgery. Case presentation A 65-year-old female patient with advanced gallbladder cancer associated with pancreaticobiliary maljunction underwent extended cholecystectomy with extrahepatic bile duct resection. The pathological diagnosis was T3N0M0 stage III A papillary adenocarcinoma with hepatic invasion. During a monthly follow-up, a diffuse hypovascular 2.0 × 1.5-cm mass was detected in the pancreatic head 6.2 years after the initial surgery. Hence, the patient underwent pancreaticoduodenectomy. Histological examination revealed T3N0M0 stage IIA well-differentiated adenocarcinoma without lymph node metastases. Marked inflammatory reaction was observed in the non-cancerous lesions of the proximal pancreatic head parenchyma containing bile pigment within ductular lumens. After 12.5 years from the initial surgery, total pancreatectomy for a 4.0 × 3.0-cm mass in the remnant pancreas was performed. Histological examination revealed T3N1M0 stage IIB moderately differentiated adenocarcinoma with lymph node metastases. Hence, surgical curative resection was achieved. Based on the pathological findings, a definitive diagnosis of triple metachronous pancreatic and gallbladder cancer was made. The pathology suggests no precursor lesions such as pancreatic intraepithelial neoplasia (PanIN) and atypical flat lesions, but marked inflammations in the non-cancerous lesions, strengthening our hypothesis that chronic inflammation induced by the pancreaticobiliary maljunction is related to carcinogenesis of the pancreas. Despite further adjuvant chemotherapy, the patient’s general condition worsened; however, she remained alive 15.2 years after the initial surgery while receiving the best supportive care. Conclusions Repeat curative surgery for triple metachronous cancer was associated with a favorable prognosis. Both the biliary tract and the pancreas should be closely monitored during follow-up among patients with pancreaticobiliary maljunction, which can be managed with curative surgery.

Access to the left atrium during transseptal puncture for radiofrequency ablation in patients with atrial fibrillation (AF) and implanted atrial septal occluder can be challenging. This is particularly true when the occluder covers the entire septum and there is no ideal puncture site. This might lead to potential difficulties in arrhythmia treatment.A 59-year-old patient with drug refractory AF, a dilated left atrium, and an implanted atrial septal occluder underwent double transseptal puncture through atrial septal occluder with subsequent pulmonary vein isolation using remote magnetic navigation. The effectiveness of the manipulation was confirmed by intraoperative stimulation from the Lasso catheter and by Holter monitoring data post-operation. It was revealed that the patient had sinus rhythm and no complications occurred. There were no shunts at the occluder level on transthoracic echocardiography, and there were no atrial tachyarrhythmias during the nine-month follow up period without antiarrhythmic drugs. The presented clinical case demonstrates the safety and efficacy of transseptal puncture through an implanted occluder in the interatrial septum to perform re-ablation using robotic magnetic navigation in a patient with AF.Received 21 October 2020. Revised 20 November 2020. Accepted 25 November 2020.Funding: The work is supported by a grant of the President of the Russian Federation No. МД-1997.2020.7.Conflict of interest: Authors declare no conflict of interest.Author contributions Drafting the article: А.V. Ponomarenko, R.E. Zhizhov, V.V. Baranova, E.V. Fisher, A.B. RomanovLiterature review: А.V. Ponomarenko, R.E. Zhizhov, V.V. Baranova, E.V. FisherIllustrations: А.V. Ponomarenko, A.B. RomanovCritical revision of the article: А.V. Ponomarenko, R.E. Zhizhov, V.V. Baranova, A.M. Chernyavskiy, A.B. RomanovSurgical treatment: N.А. Yelemessov, I.S. Peregudov, V.V. Shabanov, A.B. RomanovFinal approval of the version to be published: А.V. Ponomarenko, N.А. Yelemessov, I.S. Peregudov, R.E. Zhizhov, V.V. Baranova, E.V. Fisher, V.V. Shabanov, A.M. Chernyavskiy, A.B. Romanov

Objectives The present study analyzed surgical outcomes of laryngotracheal separation (LTS) in children with neurological disorders. The purpose of this study was to investigate respiratory impairment and severe complications after LTS in children, and identify the possibility of permanent tracheostomy without a tracheostomy tube as the safest respiratory management method. Methods Twenty‐eight patients (male:female = 16:12) with neurological disorders (6 months to 32 years) who underwent LTS between January 2012 and April 2018 were reviewed. Tracheal diameter, Cobb angle, and sternocervical spine distance (SCD) were measured to assess the potential risk and possibility of removing tracheostomy tube management. Results Tracheostomy tube could be removed shortly after LTS in 57% (16/28). However, nine of these patients developed respiratory problems that required tracheostomy tube placement 2 years after LTS. New requirements for a tracheostomy tube as a stent were strongly correlated with SCD (P 1) as well as tracheal deformity. Conclusions Respiratory management in neurologically impaired children after LTS without a tracheostomy tube is challenging because thoracic deformity during physical growth affects tracheal disfiguration. Thoracic deformities and progression of scoliosis should be considered in respiratory management approaches in children with neurological disorders, and long‐term follow‐up by computed tomography is necessary. LEVEL OF EVIDENCE IV

Background Ezrin-radixin-moesin (ERM) have been explored in many cancer processes. Moesin, as its component, has also been found to play an important role in the prognosis of cancer patients, tumor metastasis, drug resistance, and others. Especially in regulating the immunity, but most results came from direct studies on immune cells, there is no clear conclusion on whether moesin has similar effects in tumor cells. And moesin has certain research results in many cancers in other aspects, but there are few about moesin in lung adenocarcinoma (LUAD). Methods We detect the expression of moesin in 82 LUAD and matched normal tissue samples by immunohistochemistry. Besides, for the pathological feature, we did a detailed statistical analysis. And with the help of various databases, we have done in-depth exploration of moesin’s ability to enhance the extent of immune lymphocyte infiltration. Results Moesin is a poor expression in lung cancer tissues than the corresponding normal samples. And this phenomenon had a strongly associated with the prognosis and TNM stage of these LUAD patients. Moesin can enhance the infiltration of multiple immune lymphocytes in lung cancer. And this may be related to the interaction between moesin and various inflammatory molecules. Conclusions Moesin is a newly index for the prognosis of LUAD and improves the prognosis of LUAD patients by regulating a variety of inflammation-related molecules to enhance immune lymphocytes infiltration.

Purpose Large-size ports used for laparoscopic and robotic procedures will require appropriate closure to reduce the probability of trocar site complications including hematoma and hernia. Closure of these ports is done by various methods like the open method extending skin incisions, S-retractor, Carter Thomason method, and so on. Chennai port closure (CHC) method, a novel technique that had been in practice in our unit for more than 2 years, ensures direct visualization of the suture placement, and hence, the abdominal wall fascia and peritoneum are secured. Materials and Method We herein describe an easy technique for fascial closure in port size (≥ 10 cm) after minimally invasive surgery, including both laparoscopic and robotic procedures, using a cobbler needle in 151 patients in the study period between February 2017 and March 2020 for various urological procedures. This technique was done before the introduction of the trocar sheath and ensures direct visualization of the abdominal fascial closure. Results There were no major intraoperative events, additional operating time, and need for any costly instruments. No bowel injuries or trocar site hernias were documented during a mean follow-up of 28 months. Presently, this technique is used by many surgeons in our hospital without much difficulty. Conclusion The Chennai port site closure technique is an effective, simple, easy-to-apply, and safe procedure.

Objective To evaluate the clinical value of intraoperative nerve monitoring (IONM) by comparing the procedure times for thyroidectomies performed with and without IONM. Methods A prospective, randomized, controlled study was conducted on 32 patients (representing 41 nerves at risk) undergoing thyroidectomies carried out by two experienced head and neck surgeons (CC & WP). Sixteen thyroidectomies were performed without IONM (the “non‐IONM group”), while 16 thyroidectomies were performed with IONM (the “IONM group”). The measured datapoints were setup time, time to visual identification of the recurrent laryngeal nerve (RLN), time to confirm the RLN electrophysiologically, dissection time, and total operative time. Results With both surgeons, the IONM group had shorter visual times to RLN identification than the non‐IONM group (CC: 3.7 minutes vs 5.3 minutes; WP: 3.4 minutes vs 9.7 minutes). Additionally, the electrophysiological identification time for the IONM group was shorter than the visual identification time for the non‐IONM group. The setup times, dissection times, and total operative times of the 2 groups did not significantly differ (P > .05). No RLN injuries were observed. Conclusions IONM reduces the time needed for RLN identification in thyroidectomies. Functional RLN confirmation can reassure surgeons of the operative results. Moreover, use of IONM does not significantly impact setup and total operative times. Level of evidence 2.

Background The COVID-19 pandemic has rapidly spread worldwide. As it is a novel disease, we have less experience in its possible appearances. Predominantly affecting the respiratory tract, about 20–43% patients also present with extrapulmonary manifestations such as coagulation disorders with thrombotic angiopathy. Case presentation In our institution, a patient presented to the emergency department with acute abdominal pain which was caused by portal vein thrombosis. As a COVID-19 nasopharyngeal antigen swab few days earlier was negative, we performed several tests to find out its etiology. After all tests were inconclusive and the patient suffered flu-like symptoms 2 weeks before, we repeated COVID-19 molecular testing and received a positive test result. The patient was treated symptomatically and received therapeutic anticoagulation. Conclusion A COVID-19 infection can also be present without typical pulmonary symptoms. In patients with severe abdominal pain and new diagnosed portal vein thrombosis, it is important to think of a COVID-19 infection. Also, the reliability of antigen nasopharyngeal swab should be considered critically, especially if performed wrongly. We recommended to perform molecular tests when in doubt. After the diagnosis of portal vein thrombosis, immediate anticoagulation is recommended to reduce the risk of further complications like intestinal infarction.

Background. At the present time there is no agreement regarding effect of revascularisation volume on long-term results of coronary artery bypass grafting. According to some reports, incomplete revascularisation, compared with complete revascularisation, affects survival and increases the frequency of adverse cardiovascular events. Other researchers do not find such differences.Aim. This study aimed to assess the influence of incomplete revascularisation on the long-term results of coronary bypass surgery and to determine its predictors.Methods. A total of 243 patients with coronary artery disease who underwent microscope-assisted coronary artery bypass surgery were categorised into two groups. Group I included those with complete revascularisation (n = 152), while group II included those with incomplete revascularisation (n = 91). When assigning patients to groups, the volume of achieved myocardial revascularisation was determined according to the patency of grafts. The groups were compared by the late survival and by the frequency of major cardiovascular events. Logistic regression was used to analyse predictors of incomplete revascularisation.Results. The median of follow-up (interquartile range) was 802 days (426–1487 days). Survival in group 1 at 1, 3 and 5 years after surgery was 98%, 98% and 89%, respectively, while in group 2, it was 90%, 86%, and 86%, respectively (p = 0.024). Freedom from major cardiovascular events (death, myocardial infarction, repeated revascularisation, stroke) in group 1 after 1, 3 and 5 years was 91%, 89% and 77%, respectively, and in group 2, it was 78%, 68% and 68%, respectively (p = 0.005). It was revealed that diabetes mellitus (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.01–2.09), arteriosclerosis of arteries of two or more localisations (OR = 1.63, CI = 1.15–2.31), number of lesions in circumflex artery system (OR = 2.48, CI = 1.86–3.31), number of lesions in anterior descending artery system (OR = 1.61, CI = 1.14–2.28) and the diameter of the target coronary artery is less than 1.5 mm (OR = 1.3, CI = 1.22–2.38) are independent predictors of incomplete myocardial revascularisation during coronary artery bypass grafting. Male gender (OR = 0.61, CI = 0.41–0.91) and increased body mass index were associated with a reduced risk of incomplete revascularisation (OR = 0.96, CI = 0.93–0.99).Conclusion. Incomplete revascularisation worsens the prognosis after coronary bypass surgery, and is accompanied by an increase in the frequency of adverse cardiovascular events and a decrease in long-term survival. The risk of incomplete revascularisation increases in patients with diabetes mellitus, common manifestations of atherosclerosis, number of lesions in the left coronary system, as well as with a small diameter of the target coronary arteries. Male gender and increased body mass index were associated with a reduced risk of incomplete revascularisation.Received 15 June 2020. Revised 23 July 2020. Accepted 24 July 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

Background: In intestinal ischemia, reperfusion towards the injured intestine can cause further injury to the intestine itself and to remote organs. This research aimed to evaluate the influence of intestinal strangulation release (SR) before resection on the intestine outside margin of the strangulated intestine compared with subjects without intestinal strangulation release (WSR). Methods: Fourteen male Sprague Dawley rats were subjected to strangulation of one loop of the distal ileum for 4 h. In the SR group, the strangulated intestine was released for 5 min and then resected for necrotic parts. In the WSR group, the strangulated intestine was immediately resected WSR. The control group received a sham laparotomy. Four hours after the second laparotomy, the animals were sacrificed, and intestinal samples were taken for histomorphological analysis and measurement of intestinal malondialdehyde (MDA) level. Results: The injury on the histomorphological intestinal mucosa and intestinal MDA level were insignificantly higher in the SR group than in the WSR group (p>0.05). Conclusion: Intestinal SR before resection causes more tissue injury and oxidative stress on the intestine outside the strangulation section, but the difference is not statistically significant.

Objectives Although jet ventilation is frequently used during surgery for airway stenosis, little is known about distal airway pressures during jet ventilation. The objective of the study is to determine how jet pressure, flow rate, and position of the ventilation needle relate to distal airway pressure magnitude and homogeneity. Methods Two 3D models of the first five generations of the human airway tree were created. One is a duplicate of a human airway from a 15‐year‐old healthy male's computed tomography scan, and the other is an idealized symmetric model of human lung morphometry. Pressure transducers measured fifth‐generation distal airway pressures in both models. A computer‐controlled jet needle positioning system was used to ventilate the lung casts. The effects of jet needle position, jet pressure, and jet flow rate on distal airway pressure and homogeneity were measured. Results Total entrained jet flow rate was the most reliable predictor of distal airway pressure. Pressure supplied to the jet ventilation needle had a positive linear relationship with distal airway pressure; however, this relationship was dependent on the jet needle flow resistance. As the ventilation needle moved closer to the tracheal wall, ventilation homogeneity decreased. Depth into the trachea was positively correlated with sensitivity of the needle to the tracheal wall. Conclusion In this model, total entrained jet flow rate is a more robust predictor of distal airway pressure than jet inlet pressure. More homogeneous ventilation was observed in our model with the ventilation needle centered in the proximal region of the trachea., Xxx.

Objective Hearing loss is a highly disabling condition. Cochlear implantation is an established remedy if conventional hearing aids have failed to alleviate the level of disability. Unfortunately, cochlear implant (CI) performance varies dramatically. This study aims to examine the effects of duration of deafness (DoD) prior to cochlear implantation and the postoperative duration of implant experience with resulting hearing performance in postlingually deaf patients. Methods A systematic literature review and two meta‐analyses were conducted using the search terms cochlear implant AND duration deafness. Included studies evaluate the correlation between the DoD and auditory performance after cochlear implantation using monosyllabic and sentence tests. Correlation coefficients were determined using Pearson's correlation and Spearman rho. Results A total of 36 studies were identified and included data on cochlear implantations following postlingual deafness and postoperative speech testing of hearing outcomes for 1802 patients. The mean age ranged from 44 to 68 years with a DoD of 0.1 to 77 years. Cochlear implant use varied from 3 months to 14 years of age. Speech perception, which was assessed by sentence and monosyllabic word perception, was negatively correlated with DoD. Subgroup analyses revealed worse outcomes for longer DoD and shorter postoperative follow‐up. Conclusion DoD is one of the most important factors to predict speech perception after cochlear implantation in postlingually deaf patients. The meta‐analyses revealed a negative correlation between length of auditory deprivation and postoperative sentence and monosyllabic speech perception. Longer DoD seems to lead to worse CI performance, whereas more experience with CI mitigates the effect., This study aims to examine the effects of duration of deafness (DoD) prior to cochlear implantation and the postoperative duration of implant experience with resulting hearing performance in postlingually deaf patients. A total of 36 studies were identified and included data on cochlear implantations following postlingual deafness and postoperative speech testing of hearing outcomes for 1802 patients. The meta‐analyses revealed a negative correlation between length of auditory deprivation and postoperative sentence and monosyllabic speech perception.

Sexual life and fertility are compromised in end stage kidney disease both in men and in women. Successful renal transplantation may rapidly recover fertility in the vast majority of patients. Pregnancy modifies anatomical and functional aspects in the kidney and represents a risk of sensitization that may cause acute rejection. Independently from the risks for the graft, pregnancy in kidney transplant may cause preeclampsia, gestational diabetes, preterm delivery, and low birth weight. The nephrologist has a fundamental role in correct counseling, in a correct evaluation of the mother conditions, and in establishing a correct time lapse between transplantation and conception. Additionally, careful attention must be given to the antirejection therapy, avoiding drugs that could be dangerous to the newborn. Due to the possibility of medical complications during pregnancy, a correct follow-up should be exerted. Even if pregnancy in transplant is considered a high risk one, several data and studies document that in the majority of patients, the long-term follow-up and outcomes for the graft may be similar to that of non-pregnant women.

Background. A quality of surgical care evaluation based solely on workload and hospital mortality is incomplete. ECHSA Congenital Database integrated tools provide complexity-adjusted methods to evaluate surgical results and the surgical performance of a hospital, and make it possible to demonstrate hospital service level among other congenital heart programmes.Methods. Data on 2,521 operations in a population of children, including 532 newborns, with congenital heart disease (CHD) were uploaded on the European Congenital Heart Surgeons Association Congenital Database. These data were collected between 2012 and 2018 at the Filatov Children's Hospital. We compared our personal results with database mean values according to the following criteria: 1) proportion of newborns among all paediatric surgical cases, 2) hospital mortality, 3) Aristotle Basic Score (ABS) value, 4) STS-EACTS Mortality Score (MtS) value, and 5) MtS Performance value. All data on the database website were analysed using integrated database tools.Results. The proportion of newborns in the Filatov Children's Hospital was 21.1%, while the database mean value was 18.6%, and hospital mortality values were 3.89% and 3.61%, respectively. The mean ABS in the Filatov Children's Hospital was 6.78 ± 2.08, while that on the database was 6.57 ± 2.12 (Z-score = 0.075). The mean MtS values for the hospital and database were 0.74 ± 0.59 and 0.72 ± 0.64, respectively (Z-score = 0.031). The calculated MtS performance for the Filatov Children's Hospital was 0.72 ± 0.56, while that for all European respondents was 0.54 ± 0.29 (Z-score = 0.603).Conclusion. Cooperation with a multicentre international database, such as ECHSA Congenital Database, provides modern complexity-adjusted tools for evaluation of quality of care for children with CHD. The Filatov Children’s Hospital is a high-volume cardiac surgery centre that demonstrates an adequate survival rate regarding complexity level and surgical risk compared to European respondents of the ECHSA Congenital Database.Received 19 October 2020. Revised 18 November 2020. Accepted 19 November 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

Background Laparoscopic gastrectomy is an acceptable procedure for early-stage gastric cancer; however, most patients are diagnosed at an advanced stage and older age in Taiwan. The feasibility and safety of applying laparoscopic gastrectomy in daily practice remain unclear. This study aimed to examine the short- and long-term outcomes of laparoscopic gastrectomy versus open procedures. Methods From 2007 to 2015, 192 patients who underwent open gastrectomy and 189 patients who underwent laparoscopic gastrectomy for gastric cancer at a single center were included. Propensity score matching analysis was used to adjust selection biases associated with age, preoperative hemoglobin, the extent of resection, tumor size, and stage of the disease. The demographics, perioperative parameters, short-term postoperative results, and 5-year survival data were analyzed. Results Open gastrectomy was more frequently performed in the elderly, larger tumor size, advanced stage of the disease, and disease requiring total gastrectomy or combined organ resection. After propensity score matching, 108 patients with laparoscopic gastrectomy were compared to 108 patients with open gastrectomy. The morbidity rates were not different in both groups (25.9%), while hospital stay was shorter in the laparoscopic group (16.0 vs. 18.8 days, p = 0.04). The 5-year overall survival and disease-free survival were superior in the laparoscopic group (p = 0.03 and p = 0.01, respectively); however, the survival differences were not significant in the subgroup analysis by stage. Laparoscopic gastrectomy had fewer recurrences than open gastrectomy. The pattern of recurrence was not different between the groups. Conclusions Laparoscopic gastrectomy can be safely applied in both early and locally advanced gastric cancer without compromising oncologic outcomes. Trial registration Retrospective registration.

Herein, we report the successful surgical treatment of the case of a 13-year-old patient with combined pulmonary artery stenosis, critical stenosis of the xenopericardial conduit and aortic valve insufficiency after two previous operations (radical correction of the common arterial trunk during the neonatal period and replacement of the right ventricular excretory tract conduit with branch plasty at three years of age). According to echocardiography, the peak pressure gradient across the conduit was 110 mmHg, along with aortic valve regurgitation of the third degree. According to computerised tomography angiography, there was narrowing of the right pulmonary artery up to 3 mm distally along with total calcification of the conduit and branches of the pulmonary artery with an intimate fit to the chest wall. The trunk of the pulmonary artery was replaced with a valve-containing conduit CARBOMEDICS СARBO-SEAL No.25 (LivaNova PLC, London, United Kingdom); right pulmonary artery plasty was performed with a xenopericardial patch; aortic valve was replaced with CARBOMEDICS СARBO-SEAL No.23 (LivaNova PLC, London, United Kingdom), a mechanical prosthesis, and supracoronary prosthetics were used for the ascending aorta. The duration of cardiopulmonary bypasswas 309 minutes, cross-clampwas 142 minutes and circulatory arrest was 49 minutes, with 26°C hypothermia. Extubation was performed 10 hours after surgery, and he spent 3 days in intensive care. The duration of hospitalisation was 26 days. He was examined after 6 months, and there were no complaints. The presented clinical case shows that implantation of a mechanical prosthesis is justified with repeated reoperations on the outflow tract of the right ventricle and the pulmonary trunk, and it may be the surgery of choice.Received 3 September 2020. Revised 1 October 2020. Accepted 5 October 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributionsDrafting the article: S.A. Belash, M.M. AmariLiterature review: S.A. Belash, M.M. AmariIllustrations: S.S. Shevchenko, A.K. ShadrinCritical revision of the article: K.O. Barbukhatti, S.A. Belash, N.B. Karakhalis, V.A. PorkhanovFinal approval of the version to be published: K.O. Barbukhatti, S.A. Belash, S.S. Shevchenko, M.M. Amari, N.B. Karakhalis, A.K. Shadrin, V.A. Porkhanov

Background: It is new clinical interest higher serum amylase level with pancreatitis after pancreaticoduodenectomy (PD) correlates with postoperative pancreatic fistula (POPF). Nevertheless, its evidence and study were scarce. We aimed to investigate correlation of serum amylase level immediate after PD and POPF occurrence. Methods: Of 163 patients who underwent PD at between January 2009 and December 2019, retrospective analysis was conducted to identify risk factors including serum amylase level immediate after PD for POPF occurrence. Results: Overall incidence of POPF (25/163) was 15.3%. The patients occurred a POPF had significantly higher level of serum amylase on POD0 compared to in whom without a POPF (414 vs 253, p 285IU/L) and Fistula Risk Grade were correlated with POPF occurrence. In multivariable analysis, Fistula risk grade and POAP were significantly associated with developing POPF. Conclusion: In patients with higher serum amylase (>285IU/L) on POD0 with higher fistula risk grade, comprehensive management to achieve mitigation of POPF is important.

Background In Japan, the prevalence of synchronous multiple intramucosal gastric carcinoma is reported to be 5–15%. Here is a case of a synchronous small gastric carcinoma fulfilling the definite indication and curative criteria for endoscopic submucosal dissection with multiple lymph node metastases. Case presentation A Japanese woman in her fifties with a history of endoscopic resection for mucosal poorly differentiated adenocarcinoma was evaluated, with the UICC TNM classification stage being cT1aN0M0 cStageIA. She had undergone total gastrectomy with D1 + lymph node dissection. Histopathological examination revealed 16 individual sporadic lesions in the gastric body, with maximum diameter 3 mm and localization in the lamina propria. Twenty-seven nodes were resected, and metastasis of the carcinoma was revealed in 24 nodes. Conclusions Undifferentiated intramucosal gastric cancer has a relatively high probability of lymph node metastasis; however, synchronous early lesions are often overlooked. Frequent follow-up examinations may increase the detection of multiple gastric cancers.

Renal hypoxia has recently been implicated as a key contributor and indicator of various glomerular diseases. As such, monitoring changes in renal oxygenation in these disorders may provide an early diagnostic advantage that could prevent potential adverse outcomes. Blood oxygen level-dependent magnetic resonance imaging (BOLD MRI) is an emerging noninvasive technique for assessing renal oxygenation in glomerular disease. Although BOLD MRI has produced promising initial results for the use in certain renal pathologies, the use of BOLD imaging in glomerular diseases, including primary and secondary nephrotic and nephritic syndromes, is relatively unexplored. Early BOLD studies on primary nephrotic syndrome, nephrotic syndrome secondary to diabetes mellitus, and nephritic syndrome secondary to systemic lupus erythematosus have shown promising results to support its future clinical utility. In this review, we outline the advancements made in understanding the use of BOLD MRI for the assessment, diagnosis, and screening of these pathologies.

Congenital diaphragmatic hernia (CDH) is often diagnosed and treated in the perinatal period. Recurrence is a known complication that may very rarely occur years after the operation. We report here the case of a patient who had an operation for a CDH at birth that then recurred in adulthood. Given the risk of complications and the symptomatology of the patient, we decided to treat the patient surgically. We successfully performed a video-assisted thoracic surgery (VATS) procedure during which we reduced the hernia and closed the breach. Given the recurrent nature of the hernia, we decided to reinforce the repair with a mesh.

Despite recent advancement recurrent respiratory papillomatosis (RRP) remains a rare but challenging benign airway neoplasm In recent years there has been significant shifts in incidence of this disease due to changes in vaccination and prevention for human papilloma virus (HPV) and its related pathology This review will highlight the epidemiology, prevention and treatment of RRP The PubMed database was searched using relevant MeSH terms including “recurrent respiratory papillomatosis ” The titles and abstracts were reviewed to assess relevance and unrelated articles were excluded A full‐text review for select articles was performed, the data and discussions were interpreted and synthesized to create a concise update on the management of RRP With the increasing utilization of the 9‐valent and quadrivalent HPV vaccine in Australia, we have seen a significant decrease in the incidence of RRP Preliminary data in the US shows a similar trend of decreased incidence after implementation of vaccination Single dose Gardasil in developing countries has shown sustained immunization for at least 7 years Preliminary clinical trials and retrospective studies have shown the HPV vaccine may have benefit as a treatment method in addition to prevention for HPV related diseases Bevacizumab (Avastin), a VEGF monoclonal antibody, has shown promise as a systemic treatment for RRP The Corona Virus Disease 2019 (COVID‐19) pandemic has affected perioperative management of RRP RRP continues to decline in incidence since the implementation of HPV vaccination Advancement in the medical management including Bevacizumab show promise as an additional option for the management of RRP [ABSTRACT FROM AUTHOR] Copyright of Laryngoscope Investigative Otolaryngology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract (Copyright applies to all Abstracts )

Objectives We provide an appraisal of recent research on stimulation of the auditory system with light. In particular, we discuss direct infrared stimulation and ongoing controversies regarding the feasibility of this modality. We also discuss advancements and barriers to the development of an optical cochlear implant. Methods This is a review article that covers relevant animal studies. Results The auditory system has been stimulated with infrared light, and in a much more spatially selective manner than with electrical stimulation. However, there are experiments from other labs that have not been able to reproduce these results. This has resulted in an ongoing controversy regarding the feasibility of infrared stimulation, and the reasons for these experimental differences still require explanation. The neural response characteristics also appear to be much different than with electrical stimulation. The electrical stimulation paradigms used for modern cochlear implants do not apply well to optical stimulation and new coding strategies are under development. Stimulation with infrared light brings the risk of heat accumulation in the tissue at high pulse repetition rates, so optimal pulse shapes and combined optical/electrical stimulation are being investigated to mitigate this. Optogenetics is another promising technique, which makes neurons more sensitive to light stimulation by inserting light sensitive ion channels via viral vectors. Challenges of optogenetics include the expression of light sensitive channels in sufficient density in the target neurons, and the risk of damaging neurons by the expression of a foreign protein. Conclusion Optical stimulation of the nervous system is a promising new field, and there has been progress toward the development of a cochlear implant that takes advantage of the benefits of optical stimulation. There are barriers, and controversies, but so far none that seem intractable. Level of evidence NA (animal studies and basic research)., We provide an update on the development of near‐infrared stimulation of the auditory system over the past decade. In particular, we discuss the use of infrared stimulation and progress towards an optical cochlear implant.

Objectives Recent technology manufactured a nasopharyngeal videoscope with pistol-shaped grip (PG). This study aimed to assess the ergonomic feasibility of this novel device in daily ENT practice. Methods To assess the ergonomic impact of grip shape on ENT physicians, conventional grip videoscope (CG) and PG were utilized in this study. Surface electromyography (sEMG) was recorded to assess the muscle activity in the upper limb during endoscopy on a training model. Bilateral sEMG recordings were performed including thenar muscle, pronator teres muscle, brachioradialis muscle, and biceps brachii muscle. Mean value of the mean sEMG amplitude throughout the task in triplicated examinations (mMA) with each electrode, total values of four mMAs in both of the grip-side and the insertion tube-side limb muscles, and total value of all eight mMAs were calculated, and compared between CG and PG. Subgroup analyses were also performed in the experienced ENT physicians and the residents. Results PG provided significantly lower mMA values in thenar muscle and brachioradialis muscle of the grip-side limb compared with CG. Total value of four mMAs in PG was significantly lower compared with that in CG in the grip-side limb, and total value of all eight mMAs in PG was significantly lower compared with that in CG. Furthermore, total value of four mMAs in PG was significantly lower compared with that in CG in the grip-side limb, in both of the subgroups. Conclusion This is the first study to support the idea that the newly designed pistol-grip endoscope may have an ergonomic advantage over conventional endoscope for otolaryngologists in daily practice. Level of evidence 4.

Background: The supportive learning environment can enhance impartating of knowledge and skills. Objective: To assess the learning environment at the School of Medicine of the University of Nairobi using the Dundee Ready Educational Environment Measure(DREEM) tool. Methods: A cross-sectional survey carried in 2019 out among medical students during their clinical years to obtain their perceptions about the learning environment at the School of Medicine of the University of Nairobi. The DREEM tool was used for the survey. Data were entered and analyzed in SPSS version19. Comparisons were performed using analysis of variance (ANOVA). p≤0.05 was consideredstatistically significant. Results: We obtained 619 responses (77.4%) from 800 tools distributed. The total mean score of DREEM was 93.3/200. This is a 46.7%score overall indicating a poor perception of the learning environment. Year IV was the class with the poorest perception with a p

Objective To evaluate a negative pressure microenvironment designed to contain laser plume during flexible transnasal laryngoscopy. Methods The Negative Pressure Face Shield (NPFS) was previously reported as well tolerated with initial use on 30 patients. Diagnostic transnasal laryngoscopy was performed on an additional 108 consecutive patients who were evaluated by questionnaires and sequential pulse oximetry. Further study addressed operative transnasal potassium‐titanyl‐phosphate (KTP) laser laryngoscopy with biopsy done on four patients employing the NPFS. Results The previously described NPFS version 3 (v.3), a transparent acrylic barrier with two anterior instrumentation ports, was modified by repositioning the side suction port closer to the level of the nose and deepening the lateral sides, squaring off the lower projection. A post‐procedure questionnaire employing a 5‐point Likert scale ranging from no symptoms (rating of 1) to intolerable (rating of 5) identified excellent patient tolerance of the new design (v.4), among 22 patients evaluated and similar in the comparison to the 116 patients using version 3. Among the 138 patients analyzed, only one patient rated the experience as greater than “mild claustrophobia.” 100% of patients answered either “none” or “mild” to the pain and shortness of breath questions. The NPFS (v.4) was then successfully used in four patients for laser laryngoscopy with biopsy of laryngeal papilloma (3/4) and hemorrhagic polyp (1/4). Post‐procedure questionnaire identified no shortness of breath (4/4), no claustrophobia (4/4), no pain (4/4) and no significant changes in pulse oximetry during use. Conclusion Extensive experience in performing diagnostic laryngoscopy with the NPFS directed design changes leading to successful use for transnasal flexible laser laryngoscopy with biopsy in a negative pressure microenvironment. Level of Evidence Level 2b (Cohort Study).

Background: Nasal septum collections (hematoma and abscess) can lead to structural and functional abnormalities. Our objective was to assess the clinical characteristics, management and complications of nasal septal collections, and document factors associated withtheir complications. Methods: This was a retrospective study of patients managed for nasal septal collections. Socio-demographic and clinical information was recorded, and the main investigations and results noted. Follow-up and complications of septal collections were documented and the clinical factors associated with the complications explored. Results: Twenty-four patients records were studied: male: female ratio=2:1, mean age 40.1±13.1years,62.5% presented with complaints of nasal obstruction, 66.7% had antecedent nasal trauma, presentation was from 2 to 13 days,25%had co-morbid disease(s). All patients had incision and drainage of the septal collection within 1–7 h; 41.2% of the aspirated collections cultured microorganisms, 20.8% developed complications. Increased age above 45 years, co-morbidity, delayed presentation, culture-positive aspirate was all significantly associated with development of complications. Conclusion: Nasal septal collections were more common in adult males with antecedent nasal trauma; 20% developedcomplications associated with the presence of culturepositive abscesses, increased age, and duration of septal collection. Keywords: Nasal trauma, Septal hematoma, Septal abscess, Complications

Background Genetically engineered porcine donors are a potential solution for the shortage of human organs for transplantation. Incompatibilities between humans and porcine donors are largely due to carbohydrate xenoantigens on the surface of porcine cells, provoking an immune response which leads to xenograft rejection. Materials and Methods Multiplex genetic knockout of GGTA1, β4GalNT2, and CMAH is predicted to increase the rate of xenograft survival, as described previously for GGTA1. In this study, the clustered regularly interspaced short palindromic repeats/clustered regularly interspaced short palindromic repeats–associated protein 9 system was used to target genes relevant to xenotransplantation, and a method for highly efficient editing of multiple genes in primary porcine fibroblasts was described. Results Editing efficiencies greater than 85% were achieved for knockout of GGTA1, β4GalNT2, and CMAH. Conclusion The high-efficiency protocol presented here reduces scale and cost while accelerating the production of genetically engineered primary porcine fibroblast cells for in vitro studies and the production of animal models.

Background: Acute appendicitis (AA) has a lifetime risk of 8.3% with a consequent 23% lifetime risk of emergency appendectomy. In atypical presentation, making a clinical diagnosis is difficult, leading to a high perforation rate (PR) or misdiagnoses and high negativeappendectomy rates (NAR). This study aimed to establish NAR and explore the associated factors and possible attainable solutions to reduce it in urban referral hospitals in Tanzania. Methods: This was a crosssectional study with 91 consecutive patients, aged 10 years and older undergoing appendectomy for suspected AA with histological evaluation of specimens. The study was powered to detect the NAR at 95% confidence level and 80% power. Results: The histological NAR was 38.5% and the perforation rate was 25.3%. The Alvarado score (AS) was rarely applied (6%), despite ademonstrated ability in this study to decrease the NAR by half. Females were four times more likely to undergo negative appendectomy than males. Conclusion: The NAR is clinically significant as about two out of every five patients undergoing emergency appendectomy for suspected AA do not require the procedure. The AS is underutilized despite a demonstrated ability to decrease the NAR. We recommend that the AS be incorporated in the management of patients with suspected appendicitis. Keywords: Negative appendectomy rate, SubSaharan Africa, Alvarado score, Appendectomy, Suspected acute appendicitis

Objectives To evaluate the role of hospital setting on outcomes in open airway surgery by comparing patients who underwent surgery (cricotracheal resection [CTR] or tracheal resection [TR]) at a publicly funded county hospital vs a private university hospital. Methods Retrospective chart review of patients undergoing CTR or TR at two institutions; a private university hospital and a publicly funded county hospital from September 2014 to September 2019. Length of intensive care unit (ICU) stay, total time to discharge, minor and major complications were the primary endpoints. Significance was defined as a P‐value less than .05. Results There were a total of 43 patients (17 county, 26 university) who had CTR or TR during the study period. Length of stay outcomes was reported as mean length of stay ± SD. There was a significant difference in ICU stay at the county hospital (7.17 (±5.36 days) compared to the university hospital (2.52 ± 1.85 days, P

Background: Injury or even amputation of the glans or the penile shaft occurs rarely but can be a tragic circumcision-related complication. The forceps-guided technique can cause this complication due to an inability to visualize the glans before incising. This study was designed to solve this problem by transilluminating the prepuce before the incision, thus exploring whether it contains any tissue between its layers and visualizing what is being done rather than performing the procedure blindly. Methods: Forceps-guided circumcision was done on 432 males, from August 2018 to July 2019.The mean age of patients was 15.57 (1–348) days. The pulled prepuce was transilluminated, showing the prepuce and verifying that no glanular or penile tissue was involved in the forceps lock before incising. Results: The mean follow-up period was 12.45 (2–35) days. Twenty-one patients had postoperative bleeding, and six patients had a hematoma. Fourteen of the 21 patients were managed using a tight bandage; the remaining 7 patients needed surgical exploration. None of the patients had glanular or penile injury. Conclusion: Transilluminating the prepuce as a modification of forceps-guided circumcision is a protective safety step before cutting the prepuce, to eliminate the incidence of glanular or penile injuries. Keywords: Circumcision, Prepuce, Transillumination, Forceps, Complication

Background Postoperative nausea and vomiting (PONV) and postoperative pain (POP) are most commonly experienced in the early hours after surgery. Many studies have reported high rates of PONV and POP, and have identified factors that could predict the development of these complications. This study aimed to evaluate the relationship between PONV and POP, and to identify some factors associated with these symptoms. Methods This was a prospective, multicentre, observational study performed at An-Najah National University Hospital and Rafidia Governmental Hospital, the major surgical hospitals in northern Palestine, from October 2019 to February 2020. A data collection form, adapted from multiple previous studies, was used to evaluate factors associated with PONV and POP in patients undergoing elective surgery. Patients were interviewed during the first 24 h following surgery. Multiple binary logistic regression was applied to determine factors that were significantly associated with the occurrence of PONV. Results Of the 211 patients included, nausea occurred in 43.1%, vomiting in 17.5%, and PONV in 45.5%. Multiple binary logistic regression analysis, using PONV as a dependent variable, showed that only patients with a history of PONV [odds ratio (OR) = 2.28; 95% confidence interval (CI) = 1.03–5.01; p = 0.041] and POP (OR = 2.41; 95% CI = 1.17–4.97; p = 0.018) were significantly associated with the occurrence of PONV. Most participants (74.4%) reported experiencing pain at some point during the first 24 h following surgery. Additionally, the type and duration of surgery were significantly associated with POP (p-values were 0.002 and 0.006, respectively). Conclusions PONV and POP are common complications in our surgical patients. Factors associated with PONV include a prior history of PONV and POP. Patients at risk should be identified, the proper formulation of PONV protocols should be considered, and appropriate management plans should be implemented to improve patients’ outcomes.

Background As molecular advances have deepened the knowledge on low-grade glioma (LGG), we investigated the effect of higher radiation dose on the survival of IDH-wildtype (IDHwt) LGG. Methods In the current study, 52 IDHwt LGG patients who received radiotherapy were enrolled from the Chinese Glioma Genome Atlas dataset. Radiation doses > 54 Gy were defined as high-dose, whereas doses ≤ 54 Gy were defined as low-dose. We performed univariate and multivariate survival analyses to examine the prognostic role of high-dose radiotherapy. Results In total, the radiation dose ranged from 48.6 Gy to 61.2 Gy, with a median of 55.8 Gy, and 31 patients were grouped into high-dose radiation. Univariate survival analysis indicated that high-dose radiotherapy (p = 0.015), tumors located in the frontal lobe (p = 0.009), and pathology of astrocytoma (p = 0.037) were significantly prognostic factors for overall survival. In multivariate survival analysis, high-dose radiotherapy (p = 0.028) and tumors located in the frontal lobe (p = 0.016) were independently associated with better overall survival. Conclusions In conclusion, high-dose radiotherapy independently improved the survival of IDHwt LGG. This can guide treatments for glioma with known molecular characteristics.

Objectives Recurrent laryngeal nerve (RLN) injury is one of the severe complications in thyroid surgery. Therefore, intraoperative nerve monitoring (IONM) has been widely used to identify the RLN and confirm its integrity. Recently, the usefulness of continuous IONM (CIONM) with automatic, periodic stimulation to the vagus nerve during thyroid surgery was reported. This study aimed to report our experience with minimally invasive video‐assisted endoscopic endocrine neck surgery (VANS), during which, CIONM was successfully applied for the first time. Methods Consecutive patients who underwent thyroid surgery with CIONM, performed in our department using either external neck incision surgery or VANS between July 2017 and June 2019, were retrospectively analyzed. Results A total of 22 patients who underwent thyroid surgery with neck incision (14 cases; 7 men and 7 women; age, 21‐75 years [mean, 52 years]) or VANS (8 cases; 8 women, age, 20‐61 years [mean, 41 years]) were enrolled in this study. The addition of CIONM in VANS prolonged the operation's duration by approximately 30 minutes as the endoscopic surgery was technically more difficult. No intra‐ and postoperative incidence of transient or permanent RLN palsy was observed in any patient, except for three patients who underwent external neck incision surgery in whom combined resection was unavoidable due to tumor invasion of the RLN. Conclusion We reported the first successful application of CIONM during thyroidectomy using VANS. Future clinical trials should clarify the benefits of CIONM when compared to intermittent IONM in VANS. Level of Evidence 5.